COMPLICATIONS OF TRANSSCLERAL-SUTURED POSTERIOR CHAMBER IOLS

Andrew McAllister, FRANZCO and Peter Beckingsale, MBBS, FRANZCO

The implantation of an intraocular lens (IOL) into the intact capsular bag after removal of the crystalline lens provides stable fixation at a position closest to the nodal point of the eye. When faced with a patient without capsular or zonular support, where an IOL in situ needs to be exchanged, or the patient requires a secondary IOL to treat aphakia, an IOL can be placed into the anterior chamber or posterior chamber rather than leaving the patient aphakic. Fixation options in the anterior chamber include an iris-fixated lens, the previously used closed-loop anterior chamber IOLs (ACIOLs), or the modern style of open-loop ACIOLs. In the posterior chamber, an IOL can be fixated into the posterior chamber by transscleral suturing, intrascleral gluing within the ciliary sulcus, or fixation to the posterior iris surface by the haptics, the optic, or by clips.^1–3

Because of their anatomic location, posterior chamber IOLs (PCIOLs) have a theoretical advantage over anterior chamber–located IOLs. They provide better visual acuity, binocularity, and a lower incidence of strabismus than contact lenses, and they avoid the complications of ACIOLs, seen more in the rigid closed-loop lenses than the open-loop and iris-fixated lenses.^4–8 Complications of ACIOLs include irreversible corneal endothelial cell loss, pseudophakic bullous keratopathy, peripheral anterior synechiae, inflammation, and glaucoma caused by long-term anterior chamber irritation.^7,9–11 PCIOLs are indicated where these conditions are preexisting and in situations where an ACIOL may pose a higher risk of complications. These would include patients with diabetes, corneal guttata, shallow anterior chambers (< 3.0 mm), structural anterior segment abnormalities, and aniridia (Figures 37-1 and 37-2). ACIOL implantation may also be less desirable when a combined penetrating or endothelial keratoplasty is needed (Figure 37-3).^1,7,11,12

Potential disadvantages of transscleral-sutured PCIOLs include a more demanding surgical technique to introduce and fixate the IOL, longer duration of surgery compared to other methods, sutures tracking into the eye, and the risk of hemorrhage and retinal detachment caused by surgical manipulation in the region of the ciliary body.^11–13 Serious postoperative complications of transscleral-sutured PCIOLs are not infrequent, and may include knot and suture erosion,^14–16 lens tilt,¹⁵ suture breakage,^17,18 endophthalmitis,¹⁸ retinal detachment,^17,18 choroidal hemorrhage,^15,17 elevated intraocular pressure (IOP)^{9,13,17,19–22} and open-angle glaucoma (Table 37-1).^6,15,23

Surgical Technique

IMPLANT DESIGN

Recommendations for transscleral-sutured PCIOL implants include the following. The lens optic should be well polished and have a smooth edge to minimize chafing of the epithelium of the posterior iris and ciliary body. The ciliary ring has a mean diameter of 11.15 ± 0.5 mm so the total haptic diameter should be 12.5 to 13.0 mm.^24,25 The optic diameter should be at least 6 mm to compensate for any lens tilt or decentration, which occurs in 5% to 10% of patients. The haptics should have 10-degree angulation and preferably eyelets to prevent slippage of sutures. A large optical diameter IOL (7.0 mm or more) should be used in children whose scotopic pupil may have a diameter of 7.0 mm or more.1 The CZ70BD (Alcon Laboratories, Inc) polymethylmethacrylate (PMMA) IOL with a 7.0-mm optic diameter is a commonly used transscleral-sutured PCIOL, and features one eyelet on each haptic for 2-point fixation. The Akreos AO60 (Bausch + Lomb) hydrophilic acrylic IOL has suture eyelets incorporated into its plate-haptic design, which allow 4-point fixation and reduced risk of pupil-optic capture.

RIGID VS FOLDABLE IMPLANTS

Folding or placing the Akreos AO60 into an injector cartridge is preferred as it requires a smaller incision; foldable optics can be inserted through a 3.5-mm wound compared to an incision greater than 7 mm wide for the CZ70BD.²⁶ The smaller foldable IOL incision is usually self-sealing, and with the use of viscoelastics, allows better maintenance of the anterior chamber during IOL insertion and suturing.²⁷ This provides greater intraoperative surgical control, reduces operative time, minimizes suture or surgically induced astigmatism, and permits faster visual rehabilitation.²⁶

In addition, the larger incision for the PMMA optic promotes egress of intraocular fluids causing hypotony during surgery and increases the risk of choroidal hemorrhage. The frequent need to pressurize the globe, working with a soft eye, and of the need for sutures to ensure a watertight wound closure make the procedure more difficult and time consuming.^1,12 Three percent of patients develop postoperative hypotony when using PMMA lenses, which can be corrected early on by resuturing the leaking corneal incision.¹⁷ For chronic leaks around scleral sutures, an injection of autologous blood and placement of a bandage contact lens at the site may be sufficient.¹⁷

For eyes where an intraocular gas or air fill is planned, the Akreos AO60 is susceptible to optic opacification via calcium salt deposition because it is hydrophilic, which is not an issue with the CZ70BD.²⁸

METHODS OF IOL FIXATION

Transscleral-sutured PCIOLs can be fixated within the ciliary sulcus using either a 10-0 or 9-0 polypropylene or 7-0 Gore-Tex (CV-8; WL Gore & Associates) suture through scleral and conjunctival incisions. Different techniques have been described, and the optimal lens placement method remains controversial.^2,7,29,30 Technique variations involve the method of introducing the suture needle (ab externo [outside-in] or ab interno [inside-out]), of how to secure the haptic to the fixating suture, the number of fixation points, and the methods used to prevent suture and/or knot erosion.^2,29,30 The needles recommended for direct placement include the one-quarter circle taper-cut double-armed Ethicon CIF-4 (preferred for the ab interno method) and straight transchamber Sabreloc spatula double-armed Ethicon STC-6.^2,29 Alternatively the straight needle can be docked into a 28-gauge guide needle positioned 180 degrees away,³¹ or the sutures can be grasped with MaxGrip (Alcon Laboratories, Inc) ILM forceps through a 25- or 27-gauge pars plana vitrectomy port via a handshake technique.³²

Prior to the introduction of the IOL, a thorough anterior or pars plana vitrectomy around the surgical and suture insertion site, combined with removal of at least the anterior one-third of the vitreous, is recommended.12 This is to prevent the entangling vitreous with the IOL, which could cause tractional retinal detachment or cystoid macular edema.¹² Additional vitreoretinal surgery is also necessary in cases involving subluxated crystalline lenses or IOLs.¹⁹

The risk of intra- and postoperative complications increases if the needle and/or haptic placement is either too anterior (at the iris base) or too posterior (beyond the pars plicata) while aiming for the ciliary sulcus.33 It is estimated that the ciliary sulcus is located 0.8 to 0.9 mm posterior to the limbus in the vertical meridian and 0.4 to 0.5 mm posterior to the limbus in the horizontal meridian.^25,34,35 An acceptable suture entry point would be 2 mm posterior to the limbus.

Because intraocular needle placement is obscured by the iris, suture fixation of the IOL is a relatively blind procedure, and the final position of the IOL is not entirely predictable.² This was demonstrated in a study assessing transscleral-sutured PCIOL position with ultrasound biomicroscopy.³⁶ Using intraoperative endoscopic sulcus verification more precisely localizes the ciliary sulcus for haptic and suture placement, but this is not routinely used.^33,37 In patients with postoperative visual or other symptoms that suggest transscleral-sutured PCIOL dislocation, ultrasound biomicroscopy is a useful diagnostic test.¹²

Ab externo needle passage provides more precise positioning and is most likely to achieve accurate sulcus fixation.^33,38 This method of suture introduction also produces better visual acuity and reduced rates of astigmatism, cystoid macular edema, pupil distortion, suture exposure, IOL decentration, and hyphema when compared with using the ab interno approach.³⁵ Inserting the needle ab externo obliquely, midway between perpendicular to the eye wall and parallel to the iris, has a wide safety zone of entry and is the most reproducible of all other needle insertion approaches.³⁹ To reduce the amount of tissue penetrated and the risk of bleeding, a perpendicular needle insertion away from the ciliary vessels located in the horizontal meridian, such as 2 and 8 or 4 and 10 o’clock, is recommended.¹²

For hypotonic eyes or open sky implantation of the IOL during penetrating keratoplasty, ab interno suture introduction is recommended to avoid pars plicata fixation; prolapse of the ciliary processes may occur in front of the needle tip when attempting the ab externo approach.³³

Once the IOL haptic is positioned in the ciliary sulcus, the sutures are transfixed through scleral linear incisions and tied. The knotted suture tips can either be left long or cut short, or rotated in the case of fixation through sclerotomies with the Akreos AO60. The conjunctival incisions are then closed with absorbable sutures. Traditional methods to avoid suture exposure and risk of endophthalmitis are to cover suture knots with Tenon’s and conjunctiva or a partial-thickness scleral flap.12 Long-term erosion of knots is 5% to 50% with the subconjunctival method^{14,15,20,40–42} and 14.7% to 73% when using scleral flaps.^14–16 To prevent erosion of exposed knots, 2-point scleral fixation using a continuous-loop suture with knot rotation can be used; this has exposure rates of 6.7% after 24 months of patient follow-up.⁴³ Suture fixation through a corneoscleral pocket or multiple passes in a zig-zag pattern also reduce the risk of knot exposure.^29,44

Visual Outcomes

Combining transscleral-sutured PCIOLs with an anterior vitrectomy resulted in either comparable or improved visual outcomes in 71.9% of eyes, with a mean improvement of 2 Snellen chart lines of vision.⁴⁵ There are similar outcomes for visual acuity, and complications were similar regardless of whether transscleral-sutured PCIOLs were implanted as a primary or as a secondary procedure.^46,47 Other studies reported similar results and showed poorer visual outcomes for eyes with preoperative pathology, previous complicated surgery, or required removal of an ACIOL.^17–19

There is no universal consensus on the in-the-bag spherical equivalent target for transscleral-sutured PCIOLs, and because of the variability in postoperative refraction, aiming for a slightly myopic result (up to -1 diopter) can prevent a hyperopic surprise.⁴⁸

For primary insertion of implants, open-loop ACIOLs have previously been reported to have better visual outcomes than transscleral-sutured PCIOLs, with postoperative Snellen best corrected visual acuity of 6/12 or better in 71.1% compared to 47.1%, respectively. This might relate to longer operating time for transscleral-sutured PCIOL insertion (89.5 ± 27.6 minutes compared to 62.9 ± 15.1 minutes for ACIOLs) resulting in more light-induced cystoid macular edema.^13,49 More recent studies have found no significant difference in visual outcomes and complication rates among ACIOLs, iris-fixated IOLs, and transscleral-sutured PCIOLs.^50–53 A complete anterior vitrectomy and postoperative topical nonsteroidal anti-inflammatory can help prevent the occurrence of cystoid macular edema, which commonly occurs 1 to 3 months after surgery in 5.5%⁵ of secondary transscleral-sutured PCIOLs.² Nd:YAG laser vitreolysis or repeat vitrectomy may be necessary if there is postoperative vitreous incarceration. The passage of sutures through the ciliary body and uveal/iris chafing by the IOL may also cause chronic low-grade inflammation responsible for late-onset cystoid macular edema.¹

Lens tilt greater than 5 degrees will result in refractive error and poorer visual outcomes.⁵⁴ Sulcus IOL tilt or decentration occurs in 5% to 10% of patients,¹ which is a 2-fold increase compared to IOLs placed in the bag (6.35 vs 3.18 degrees).⁵⁵ The theoretical reduction in IOL tilt with the 4-point fixation of the Akreos AO60^56,57 has not yet been compared to the 2-point fixation of the CZ70BD in a study.

Declines in postoperative corneal endothelial cell counts and visual acuity are comparable in transscleral-sutured PCIOL and open-loop ACIOL eyes for up to 3 months postoperatively.¹⁹ It is suggested that any postoperative endothelial cell loss may be due to surgical trauma rather than the presence of the IOL.¹³

Complications

Generally few intraoperative complications occur during placement of a transscleral-sutured PCIOL.⁴⁵ During the postoperative period, complications are relatively common, with 53.7% (95% CI: 42.3% to 64.7%) of cases having at least one postoperative complication and 15.8% requiring at least one postoperative surgical procedure.⁴⁵

Ocular hypertension is the most commonly encountered complication, affecting 30.5% of eyes at a mean of 106 days postoperatively; 48% of cases occur within 1 week following IOL insertion, and 44% of these patients have a prior glaucoma history (relative risk = 2.3, 95% CI: 1.2 to 3.9, Fisher’s exact P = .026).⁴⁵ The ocular hypertension may be transient (28%), longer term but controlled with medication (60%), or longer term and not controlled (12%). These results were slightly better than another large study evaluating postoperative IOP and glaucoma with transscleral-sutured PCIOL insertion.¹⁹ The incidence of glaucoma between open-loop ACIOLs and transscleral-sutured PCIOLs appears to be similar.⁷ Risk factors for postoperative ocular hypertension include a past history of glaucoma, ocular trauma, treatment of retinal detachment with silicone oil, use of intraoperative viscoelastic substances, hyphema, and corticosteroid use.¹⁷

Ocular hypotension can also occur (6.1%); it is important to identify and repair any leaking surgical wound.⁴⁵ Postoperative corneal edema (6.1%) as well as hyphema (9.8%) may also occur, but most resolve without treatment.⁴⁵

Choroidal hemorrhage has been reported to occur in up to 3.2% of eyes.^15,17 Risk factors for hemorrhage are prolonged duration of surgery, suture placement at 3 and 9 o’clock, double-suture passes, hypotony, removal of residual lens material, extensive vitrectomy, repair of large iris defects, and iridoplasty.^2,12 Contributing patient risk factors include older age, bleeding disorders or anticoagulation, hypertension, peripheral vascular disease, glaucoma, aortic stenosis, emphysema, and prior eye surgery.¹²

Young patients appear to be at greater risk for retinal detachment following transscleral-sutured PCIOLs because of coexisting ocular pathology and the natural attachment of the posterior hyaloid. The risk of retinal detachment from ectopia lentis and axial myopia ranges from 9% to 19%.^17,58 Retinal detachment after transscleral-sutured PCIOL insertion without vitrectomy occurs in 1.1% to 6.0% of patients.⁷ With accompanying pars plana vitrectomy, 8.2% experience a retinal detachment¹⁷ while with an anterior vitrectomy the rate is 4%¹⁸ to 4.9% at an average of 53 weeks.⁴⁵ Retinal tears commonly occur alongside the axis of fixation sutures, and risk factors include previous trauma, myopia more than 1 diopter, vitreous hemorrhage, and traction to the vitreous base, which should ideally be reduced by intraoperative vitrectomy.2

Studies with long-term follow-up have reported high rates of postoperative suture-related complications.^7,17,18,45 Exposure of the sutures or knots are common (11% at an average of 81.6 weeks), and breakage of the 10-0 polypropylene suture is a significant long-term problem, although the reported incidence varies. For instance, 27.9% of eyes in one study had suture rupture on average 4 years after surgery; 49% of young patients may require further surgery with 57% of these cases due to haptic suture breakage.¹⁷ In another study where 40.2% of eyes had more than 4 years of follow-up, 6% of eyes showed rupture of the polypropylene sutures at a mean of 4.9 years following surgery. Four cases were in patients younger than 40 years. This represented 30.7% of the eyes in this age group with a relative risk of 21.2 compared to older patients.⁴⁵ In other studies, suture breakage ranged from 24% of patients after 7 to 10 years of follow-up,¹⁸ compared to no suture ruptures after more than 12 years of follow-up.⁵⁹ It has been postulated that patients with primary familial bilateral ectopia lentis may carry an enzyme that degrades polypropylene or have some other effect on polypropylene sutures.³ However, higher breakage rates in younger patients could more likely be due to an active lifestyle associated with continuous microtrauma, combined with biodegradation of the polypropylene and gravitational forces.¹⁷ From a histological study, implant stability was dependent upon intact scleral sutures rather than fibrous encapsulation or correct placement of the haptic in the ciliary sulcus.⁴⁰ As a result, IOL dislocation will occur if sutures are inadvertently removed or if suture fatigue occurs.^17,60 In eyes where dislocation of the transscleral-sutured PCIOL has occurred, replacement with an ACIOL may provide better long-term visual outcomes.⁶¹ To increase the longer-term stability of sulcus IOLs, 9-0 polypropylene and 7-0 Gore-Tex are used. The suture durability must be weighed against the possible increased risk of endophthalmitis associated with a larger knot and suture track.^2,8 In one study, 7-0 Gore-Tex with either the Akreos AO60 or CZ70BD in 85 eyes had no suture breakage with follow-up ranging from 3 to 33 months.⁶² A late endophthalmitis rate of 4%¹⁸ due to exposed sutures can be reduced by covering the sutures with scleral flaps, leaving knotted suture ends long, rotating knots into the sclera, tying the knot within the depths of a partial-thickness scleral incision, or creating a corneoscleral pocket.^2,29 Passing the externalized 10-0 polypropylene suture at least 5 times through the sclera in a zig-zag pattern can also avoid suture exposure while stabilizing the IOL.⁴⁴

Conclusion

Despite the relatively common rates of complications associated with transscleral-sutured PCIOLs, the improved quality of life from not requiring aphakic contact lenses or spectacles generally justifies the risks of surgery.¹⁷

Favorable IOL location is a major advantage of transscleral-sutured PCIOLs and they provide good visual outcomes. Severe loss of vision due to serious and progressive complications are rare. We await longer-term follow-up of patients with transscleral-sutured PCIOLs. Suture erosion and rupture, particularly in young patients, can occur many years after implantation, and patients should be counseled about potential complications during the consent process. There continues to be much debate over which is the safest and most efficacious IOL procedure for patients lacking adequate capsular support. Although there are differences in the difficulty of implantation, the duration of surgery, and complication rates, modern iris claw and open-loop ACIOLs, iris-fixated IOLs,⁷ and scleral-glued IOLs all have similar reported outcomes in the literature.

References

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